Case: An 89-year-old female complains of a “stabbing chest pain”

Posted: January 7th, 2023

Select one of the following cases to discuss. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
Case 1: An 89-year-old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints.
Case 2: A 58-year-old male presents with a complaint of severe chest pain over the last hour. He states that he did not call 911 because he cannot afford an ambulance.
Case 3: A 15-year-old immigrant was brought to the clinic by her mother because patient complains of shortness of breath, chest pains, diaphoresis and easy fatiguability. She claims she has had on and off bouts of tonsillitis since she was a child that resulted in tonsillectomy surgery when she was 12. Last week, she was unable to participate in the cheer leading tryouts because of knee pain and a rash that she noticed on her trunk for the past 2 weeks.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
-Pertinent positive findings that validate your main diagnosis
-Pertinent negative findings that make you think of other differential diagnoses
-Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
Initial post must have a minimum of 300 words, excluding references. chose case #1
Case: An 89-year-old female complains of a “stabbing chest pain” and points to the area just below her scapula at the right mid-clavicular line. She states that she had an upper respiratory infection last week that “just seems to hang on.” No other complaints.

Questions:
Can you describe the pain in more detail? On a scale of 1-10, how would you rate the intensity of the pain?
Have you experienced this type of pain before? If so, how often and when was the last time?
Do you have any other medical conditions or take any medications?
Have you had any changes in appetite or weight recently?
Do you have a history of smoking or tobacco use?
Physical Exam Elements:
Check vital signs, including blood pressure, heart rate, and oxygen saturation
Inspect the chest and listen to lung sounds
Palpate the chest and back for tenderness or masses
Assess for any signs of distress, such as shortness of breath or diaphoresis
Further Testing:
Electrocardiogram (ECG) to assess for cardiac abnormalities
Chest x-ray to evaluate for any structural abnormalities or infections
Labs, including a complete blood count (CBC) and cardiac enzymes, to assess for any underlying conditions that may be contributing to the chest pain
SOAP Format:
Subjective: The patient is an 89-year-old female who presents with a complaint of stabbing chest pain located just below her scapula at the right mid-clavicular line. She reports having an upper respiratory infection last week that has not improved. No other complaints.
Objective: Vital signs are within normal limits. Lung sounds are clear. No tenderness or masses are palpated on the chest or back. No signs of distress are noted.
Assessment: The patient’s complaint of chest pain and recent upper respiratory infection raises concern for possible pneumonia. The location of the pain and absence of other symptoms also suggest the possibility of musculoskeletal pain or costochondritis.
Plan:
Pharmacotherapy: Prescribe antibiotics to treat possible pneumonia and consider pain management with nonsteroidal anti-inflammatory drugs (NSAIDs) if musculoskeletal pain is suspected.
Diagnostics: Order an ECG, chest x-ray, and labs, including a CBC and cardiac enzymes, to further evaluate the cause of the chest pain.
Health Education and Lifestyle Changes: Discuss the importance of maintaining good respiratory hygiene and taking prescribed medications as directed. Encourage the patient to follow up with her primary care provider if her symptoms do not improve.
Age-Appropriate Preventive Care: Recommend pneumococcal and influenza vaccinations to prevent future respiratory infections.
Follow-Up: Schedule a follow-up appointment in 1 week to assess the patient’s response to treatment and address any further concerns.
According to national guidelines from the Centers for Disease Control and Prevention (CDC), older adults, especially those over 65 years of age, are at increased risk for developing pneumonia and should receive the pneumococcal vaccine to prevent this infection (CDC, 2019). NSAIDs are also a recommended treatment option for musculoskeletal pain, with evidence suggesting that they may be more effective than acetaminophen in reducing pain intensity (Cochrane, 2018). In addition to pharmacotherapy, it is important to consider other factors that may be contributing to the patient’s chest pain, such as cardiac issues, and to provide appropriate diagnostic testing and follow-up care.

References:

Centers for Disease Control and Prevention. (2019). Pneumococ